Medicare Compliance & Reimbursement

Hefty fines and long prison sentences epitomize 2018 settlements.

The federal government has been cutting back on regulations over the past year. But if you think that means the enforcement agencies are easing up, you're in for a surprise. Million-dollar settlements that bring jail time dot the 2018 roster of cases - and it's only February.

Fraud and Upcoding Net MD 13 Years in Prison, Millions in Returns

The DOJ points to greed as the primary factor that led New York-based surgeon, Syed Imran Ahmed, MD, to commit healthcare fraud, filing millions in fraudulent claims and then lying about them to Medicare. "Dr. Syed Ahmed treated Medicare like a personal piggy bank, stealing over $7.2 million by making fraudulent claims for medical procedures he never performed," said Richard P. Donoghue, U.S. Attorney for the Eastern District of New York in a Department of Justice (DOJ) release on the case. "Dr. Ahmed will now pay the price for violating the trust that Medicare places in doctors."

After reporting to CMS that he'd conducted "wound debridement" services and "incision-and-drainage" procedures that he didn't, Ahmed then claimed he'd performed surgeries that he hadn't and billed Medicare for them, the DOJ release suggested. Furthermore, the surgeon tried to upcode the bogus surgeries by statingtheir Place-of-Service (POS) as the operating room instead of his office, the report showed.

Result: In addition to paying back the $7,266,008.95 he fraudulently received from Medicare, Ahmed was fined $20,000 and given a 13-year prison sentence for "one count of healthcare fraud, three counts of making false statements related to healthcare matters, and two counts of money laundering," noted theDOJ.

False Claims Suit Renders Massive $16 Million Judgment Against MRI Company

Delaware magnetic resonance imaging (MRI) provider, Orthopaedic and Neuro Imaging LLC (ONI), felt the DOJ's sting after the feds delivered a whopping $16,223,091.38 judgement against the organization for false claims, mentioned a DOJ release on the case. ONI's owner, Richard Pfarr, wasn't exempt from the DOJ's wrath either, and received his own $6,125,947.13 judgment.

Qui tam details: Pfarr and his company "knowingly submitted false claims to Medicare by administering contrast dye during magnetic resonance imaging (MRI) scans on patients without proper supervision by a physician," noted the report. The feds were alerted to the illegal activity by former employee, Robin White, in this qui tam case under the False Claims Act (FCA). Ms. White is eligible for 18 percent of the recovered Medicare funds from the case, the DOJ said.

"The U.S. Attorney's Office for the District of Delaware is committed to combating health care fraud and protecting Medicare beneficiaries using all available remedies," cautioned David C. Weiss, Acting U.S. Attorney for the District of Delaware. "This case exemplifies the utility of the False Claims Act to deter fraudulent conduct, protect patient safety, and save taxpayer dollars."

Long Prison Sentences Mark Illegal Opioid Distribution and Prescription Cases

The death toll continues to rise under the yoke of America's opioid epidemic. So it is no surprise that the feds are on the warpath when it comes to going after physicians who add to the problem.

In Kentucky: In a recent plea agreement, Bowling Green, Kentucky-based former physician, Charles Fred Gott, settled terms with the DOJ for a 96-month prison stint, indicated a DOJ release.

Between 2010 and 2013, "Gott admitted to conspiring with members of his office and others to knowingly and intentionally distribute and dispense, not for a legitimate medical purpose in the usual course of professional practice, Schedule II, Schedule III and Schedule IV controlled substances," the brief noted.

But there's more: Not only did Gott jump on the opioid distribute-and-dispense train, the physician also upcoded claims and performed "medically unnecessary spirometry tests for patients and electrocardiogram (EKG/ECG) tests for patients," the DOJ said. For all of the above fraudulent activity, Gott may have to forfeit and return all his Medicare and Medicaid proceeds.

In Michigan: Former doctor, Rodney Moret, one of five defendants in drug-scam case, ran a "pill mill" of sorts through his Southfield, Michigan practice, Advance Care Services (ACS), which was supposed to offer pain management and HIV-infusion services, said a DOJ release on the case. Instead of serving his patients, Moret billed Medicare for "examinations and tests that were not conducted properly or not conducted at all" and prescribed controlled substances for medically unnecessary reasons - and then through nefarious channels sold the illegal drugs on the Michigan streets, the report noted.

Worse yet: Moret was guilty of distributing more than "700,000 dosage units of Hydrocodone, (Vicodin, loratab), more than 240,000 dosage units of Alprazolam, and more than 2 million milliliters of promethazine with codeine cough syrup" spanning from 2010 to 2015, the report said. The doctor's crimes, which also included sexually assaulting his most vulnerable patients, fetched a mighty charge: 75 months in prison for prescribing and distributing more than $15 million in drugs and $6 million in healthcare fraud. Moret's medical license was also revoked for his actions.

"Rodney Moret, a former physician, intentionally fueled the local opioid epidemic by over prescribing addictive medications to patients for his own personal gain," said Timothy Waters, Acting Special Agent in Charge, Detroit Division of the FBI, in the DOJ release. "The message should be clear, any doctor or healthcare professional who prioritizes profit or does harm to their patients under the guise of providing health care will be subject to the full investigative resources of the FBI and our law enforcement partners."

Resource: To read more about these fraud and abuse cases, visit https://oig.hhs.gov/fraud/enforcement/criminal/index.asp.